Jain, Akhil

Cerebral embolic protection devices (CEPD) during transcatheter aortic valve replacement (TAVR) have been shown to lower the risk of stroke during the procedure. However, their long-term and clinical effects on neuro-cognition are unknown. Therefore, we hypothesized the benefit of CEPD in TAVR patients with a prior history of stroke or transient ischemic attack (TIA). National Inpatient Sample (2019) and International Classification of Diseases, 10th Revision codes were used to identify patients undergoing TAVR with prior stroke or TIA. Propensity-matched analysis was performed to adjust for baseline characteristics and comorbidities. Primary outcome measures were postoperative stroke and all-cause mortality. Length of stay and hospital cost were secondary outcomes. Of 8450 unmatched TAVR patients with prior stroke or TIA in 2019, 1095 (13%) utilized CEPD. After propensity matching previous myocardial infarction (MI), coronary artery bypass grafting, and drug abuse were higher in the TAVR-only cohort. Postoperative stroke rate (1.4% vs 2.2%; P = 0.081) and odds [adjusted odds ratio (aOR), 0.48; 95% confidence interval (CI), 0.11–2.17; P = 0.341] were lower in the CEPD group. There was no difference in all-cause in-hospital mortality between the 2 groups (0.9% vs 1.0%). Length of stay (3 vs 2 days, P <0.001) and hospital expenditure ($172,711 vs $162,284; P = 0.002) were higher for the TAVR-only cohort. CEPD in TAVR patients with prior stroke or TIA did not show statistically significant postoperative stroke benefits. However, further larger-scale prospective studies are needed to evaluate the long-term neurocognitive benefits of CEPD in these patients. As the use of TAVR continues to expand, optimizing peri-procedural strategies such as the use of CEPD remains a critical area of research to improve patient outcomes.

Prediabetes is a risk factor for ischemic stroke in atrial fibrillation (AF) patients, yet, its impact on recurrent stroke in AF patients remains understudied. Using the 2018 National Inpatient Sample, we investigated the link between Prediabetes and recurrent stroke in AF patients with prior stroke or transient ischemic attack (TIA). Among 18,905 non-diabetic AF patients, 480 (2.5%) had prediabetes. The prediabetic group, with a median age of 78, exhibited a two-fold higher risk of recurrent stroke compared to the non-prediabetic cohort (median age 82), as evidenced by both unadjusted (OR 2.14, 95% CI 1.72–2.66) and adjusted (adjusted for socio-demographics/comorbidities, OR 2.09, 95% CI 1.65–2.64, p < 0.001). The prediabetes cohort, comprising more male and Black patients, demonstrated associations with higher Medicaid enrollment, admissions from certain regions, and higher rates of hyperlipidemia, smoking, peripheral vascular disease, obesity, and chronic obstructive pulmonary disease (all p < 0.05). Despite higher rates of home health care and increased hospital costs in the prediabetes group, the adjusted odds of all-cause mortality were not statistically significant (OR 0.55, 95% CI 0.19–1.56, p = 0.260). The findings of this study suggest that clinicians should be vigilant in managing prediabetes in AF patients, and strategies to prevent recurrent stroke in this high-risk population should be considered.

Background: Impaired left ventricular (LV) global longitudinal strain (GLS) is associated with worse outcomes in patients with severe aortic stenosis (AS). However, its prognostic value in patients with moderate AS is still unknown. The aim of this study is to investigate the impact of LV GLS on outcomes of patients with moderate AS. Methods: PubMed/Medline, Scopus, and Google Scholar databases were systematically reviewed to find relevant studies through June 2023 reporting data on the relationship between the LV GLS and long-term mortality in patients with moderate AS. Binary random effects models were used to estimate pooled odds ratios (OR) and 95% confidence intervals (CI). I2 statistics were used to interpret heterogeneity, with I2>75% indicating substantial inter-study variation. Leave-one-out meta-analysis was performed to evaluate the effect of each study on the overall estimate. A p<0.05 was considered statistically significant. Results: A total of 172 studies were reviewed, and 4 studies between 2000-2023 were included in our meta-analysis with a median follow-up of 48.5 months and GLS cut-off varying from 11% to 16%. The pooled univariate analysis revealed a significant association between LV GLS and long-term mortality in patients with moderate AS with a pooled OR of 2.02 (95CI 1.04-3.93) p=0.04, I2=94.25%. The multivariate analysis, after adjusting for overall modifiable risk factors, yielded significant results, with an adjusted odds ratio (aOR) of 1.56 (95CI 1.21-2.01) p<0.01, I2=89.48%. Sensitivity analysis, using leave-one-out method, demonstrated robustness and stability of the results with aOR 1.56 (95CI 1.21-2.01) p<0.01. Conclusions: In patients with moderate AS, impaired LV GLS is associated with an increased risk for all-cause mortality. If further randomized studies confirm the prognostic ability of impaired GLS, moderate AS can be redefined, and GLS can be considered in determining the optimal timing for aortic valve intervention.

Background: Catheter ablation (CA) is an effective and potentially curative treatment in patients with atrial fibrillation (AF). However, the recurrence of AF following CA treatment in cases of persistent atrial fibrillation (PeAF) remains a significant concern. This study aims to establish a correlation between the peak flow velocity of the left atrial appendage (LAAV) and the AF recurrence post-CA for PeAF. Methods: PubMed/Medline, EMBASE, and SCOPUS databases were systematically reviewed to find studies through June 2023 reporting data on the relationship between the LAAV and the recurrence of AF in individuals who have undergone CA for PeAF. Binary random effects models were used to estimate pooled outcomes. I2 statistics were used to interpret heterogeneity, with I 2 >75% indicating substantial inter-study variation. Leave-one-out meta-analysis was performed to evaluate the effect of each study on the overall estimate. A p<0.05 was considered statistically significant. Results: A total of 9 studies between 2000-2023 were included in our meta-analysis. The pooled univariate analysis revealed no association between LAAV and recurrence of AF in individuals who have undergone CA with a pooled OR of 1.09 (95CI 0.96-1.22) p=0.45, I2=86.59%. The multivariate analysis, after adjusting for overall modifiable risk factors, yielded significant results, with an adjusted odds ratio (aOR) of 1.41 (95CI 1.15-1.74) p<0.01, I2=85.24%. Sensitivity analysis, using the leave-one-out method&nbsp;demonstrated the robustness and stability of the results, indicating that no single study disproportionately influenced the overall&nbsp;findings with aOR 1.41 (95CI 1.15-1.74) p<0.01. Conclusions: This meta-analysis revealed that low LAAV is associated with high-risk of AF recurrence following CA. Identifying a specific subgroup of individuals at high risk of AF recurrence with the help of pre-CA LAA velocity will facilitate the early institution of alternative treatment strategies.

Background: The use of cannabis in cancer patients has gained significant attention due to its analgesic properties, which help alleviate cancer-related pain. Studies have also shown the interference of cannabis with the coagulation system. We aimed to study the impact of cannabis use disorder (CUD) and Pulmonary embolism (PE) on outcomes in female breast cancer survivors, considering reports suggesting significant overlap between recreational and medicinal use. Our objective was to compare outcomes in CUD+ (with cannabis use disorder) and CUD- (without cannabis use disorder) cohorts to gain critical insights into this group and understand the impact of CUD on PE-related hospitalization and outcomes. Methods: National Inpatient Sample (NIS) data from 2020 was utilized in order to analyze inpatient cohorts of PE hospitalizations. The International Classification of Diseases 10 (ICD 10) codes for pulmonary embolism, cannabis use disorder, and female breast cancer were utilized to classify cohorts. All cases of female breast cancer and pulmonary embolism with an age &gt;18 years were included in the final analysis. The primary outcome was the impact of CUD on PE-related hospitalizations in female breast cancer survivors. We also compared demographic correlations and comorbidities affecting outcomes between cohorts. Results: This study included a total of 508065 admissions among breast cancer survivors, with a median age of 74 years for the entire cohort. The prevalence of PE admissions was lower in CUD+ cohort compared to CUD- cohort (1.3% vs. 2.1%). The CUD+ cohort was relatively younger (median 66 vs 74 years, p&lt;0.001). Overall, admission rates were higher among white patients (77%) and this trend was statistically significantly higher in the 76-100 th percentile household income group (p&lt;0.002) compared to CUD+(50%) and CUD-(26.5%). Most admissions were non-elective (95.4%), with no statistical significance between CUD- and CUD+ patients (p=0.16). The majority of readmissions occurred in urban teaching hospitals (75.5%), with no significant difference observed between CUD- and CUD+ patients (p=0.111). Regionally, the South had a higher admission rate (37.2%) compared to other regions and this difference was statistically significant (p&lt;0.001) between CUD- and CUD+ patients. Among the coexisting comorbidities, hypertension showed a significant difference between CUD- (70%) and CUD+(37.5%) patients (p&lt;0.001). Alcohol use disorder (p&lt;0.001) and cancer (p&lt;0.001) had significant associations with CUD+, along with prior myocardial infarction (p=0.005) and drug use (p&lt;0.001) were significantly associated with CUD+.Furthermore, there was difference in routine patient disposition between between CUD-(45.3%) and CUD+(37.5%),(p=0.033) and length of stay (4 VS 2 days), (p=0.033) and cost of stay (47033 vs 27668 $), (p=0.017). The multivariable logistic regression analysis showed that the odds of PE-related hospitalization in CUD+ vs CUD- cohorts among female breast cancer survivors were not statistically significant, with an OR of 0.79 (CI: 0.38-1.62, p=0.512). Subgroup analysis by age demonstrated no statistically significant differences in odds for PE-related hospitalization between CUD+ and CUD- cohorts. For the age group of 18-44 years, the OR was 1.37 (CI: 0.18-10.60, p=0.762). In the 45-64 years age group, the OR was 0.48 (CI: 0.15-1.53, p=0.215), and for those aged ≥65 years, the OR was 1.32 (CI: 0.48-3.67, p=0.590). Furthermore, the analysis by race indicated that the odds of PE-related hospitalization did not reach statistical significance in both white and black female breast cancer survivors with CUD. For white patients, the OR was 0.64 (CI: 0.23-1.73, p=0.375), while for black patients, the OR was 1.15 (CI: 0.38-3.46, p=0.804). Conclusion: Among female breast cancer survivors, the presence of CUD did not show a statistically significant impact on the odds of PE-related hospitalization. Subgroup analysis by age and race also revealed no significant differences in the odds of PE-related hospitalization between CUD+ and CUD- cohorts. These findings underscore the importance of considering CUD when managing pulmonary embolism in breast cancer survivor females and emphasize the need for further research to understand the complex interplay between these factors.

Abstract Background Inflammation plays a potential role in heart failure (HF) etiology and prognosis. Neutrophil-to-Lymphocyte ratio (NLR) is a simple, routinely available lab criteria. In this meta-analysis, we sought to investigate the role of NLR on HF outcomes which remains unexplored. Methods PubMed, Embase and Scopus were systematically screened to find studies through August 2022, reporting data on association of HF related outcomes [all-cause mortality (ACM), cardiovascular (CV) death, in-hospital, HF readmissions and composite events] and NLR. Random effects models and I2 statistics were used to estimate pooled odds of outcomes and heterogeneity. Leave one out sensitivity analysis was performed. Results A total of 11 studies (6 retrospective and 5 prospective, 4 studies from Asia and Europe each, 2 from the US and 1 multicenter study) including 12954 patients (mean age: 69 years, Males 57.2%) from 2011 to 2022 with an average follow up duration of 54.8 months were included. Elevated NLR was significantly associated with ACM (aOR 1.80, 95%CI 1.46-2.22, p&lt;0.01, Table 1), HF readmissions (aOR 2.53, 95% CI 1.60-3.99), in-hospital mortality (aOR 3.26, 95% CI 1.76- 6.02), CV mortality (aOR 1.84, 95%CI 1.03-3.31) and composite CV outcome including heart transplant (OR 2.07, 95% CI 1.32-3.25), p&lt;0.001. Conclusion Elevated NLR was significantly associated with worse outcomes in HF patients. The NLR test might potentially be useful in identifying high-risk HF patients and curtail worse outcomes.

Background: Obstructive sleep apnea (OSA) increases the risk of stroke and cardiovascular diseases. However, its impact on geriatric patients with a prior history of stroke/transient ischemic attack (TIA) has not been adequately studied. Methods: We utilized the 2019 National Inpatient Sample in the US to identify geriatric patients with OSA (G-OSA) who had a prior history of stroke/TIA. We then compared subsequent stroke (SS) rates among sex and race subgroups. We also compared the demographics and comorbidities of SS+ and SS− groups and utilized logistic regression models to assess outcomes. Results: Out of 133,545 G-OSA patients admitted with a prior history of stroke/TIA, 4.9% (6520) had SS. Males had a higher prevalence of SS, while Asian-Pacific Islanders and Native Americans had the highest prevalence of SS, followed by Whites, Blacks, and Hispanics. The SS+ group had higher all-cause in-hospital mortality rates, with Hispanics showing the highest rate compared to Whites and Blacks (10.6% vs. 4.9% vs. 4.4%, p < 0.001), respectively. Adjusted analysis for covariates showed that complicated and uncomplicated hypertension (aOR 2.17 [95% CI 1.78–2.64]; 3.18 [95% CI 2.58–3.92]), diabetes with chronic complications (aOR 1.28 [95% CI 1.08–1.51]), hyperlipidemia (aOR 1.24 [95% CI 1.08–1.43]), and thyroid disorders (aOR 1.69 [95% CI 1.14–2.49]) were independent predictors of SS. The SS+ group had fewer routine discharges and higher healthcare costs. Conclusions: Our study shows that about 5% of G-OSA patients with a prior history of stroke/TIA are at risk of hospitalization due to SS, which is associated with higher mortality and healthcare utilization. Complicated and uncomplicated hypertension, diabetes with chronic complications, hyperlipidemia, thyroid disorders, and admission to rural hospitals predict subsequent stroke.

Background: Bariatric surgery (BS) has been shown to be beneficial in improving co-morbid conditions in morbidly obese patients. Long-term cardiovascular complications remain undefined and warrant further investigation. We examined the prevalence and risk of atrial fibrillation (AF) in obese patients who underwent BS. Methods: PUBMED/Medline, SCOPUS, EMBASE databases were systematically reviewed using relevant keywords to search prospective and retrospective studies reporting AF with long-term (at least >1-year follow-up) follow-up in patients who had undergone BS. Random effects models were used for meta-analysis and subgroup analysis. I 2 statistics was used to identify substantial (>75%) heterogeneity. Results: Nine studies (3 USA, 2 UK, 4 Sweden) including 24,164 patients who had undergone BS (mean BMI cut off: 35, mean age 42 years) with 29,330 controls were included in the analysis with a median follow-up of 8 years. Pooled prevalence of AF was lower in BS arm (3.0%, 95%CI: 1.4%-5%) as compared to non-BS arm (3.8%, 95% CI: 1.8%-5.0%). The Forest Plot (Fig. 1) depicts significantly reduced odds of having AF in patients who have undergone BS vs controls (OR: 0.74, 95%CI: 0.60-0.91, I 2 =70.2%, p<0.01). Sensitivity analysis using the leave-one-out method did confirm equivalent results. On subgroup analysis, AF prevalence in the BS group was slightly higher in studies with a mean age of ≥50 years (4.8%, 0-12%) as compared to cohorts with mean age <50 (2.0%, 1.4-5.0%). The pooled rate of AF was low on short-term follow-up compared to long-term follow-up after BS: 1.5% (0.9-2.5%) in 1-5 years, 1.9% (0.2-4.5%) in 6-10 years, 5.4% (0-13.9%) ≥10 years of BS. Conclusions: Obese patients undergoing BS had nearly 25% lower risk and lower pooled rate of AF when compared to controls over 8 years of follow-up. The protective effect of BS on reduced risk of AF was seen to gradually wane over longer follow-up which warrants continued efforts to effectively control CVD risk factors.